Session 99, February 13, 2019

Stefanie Lin, RN/Clinical Analyst, Cleveland Clinic

Christine V. Chambers BS, MT, Donation Coordinator, Cleveland Clinic

Novel EHR Tools to Assist with

Organ Procurement Workflows

Stefanie Shimko-Lin, RN

Christine V. Chambers, BS, MTS

Have no real or apparent conflicts of interest to report.

Conflict of Interest

• What if?

• Organ Procurement Organizations

• Legal Requirements

• Barriers to Organ Donation

• Team Roles

• Previous Workflow

• Solution

• User Feedback

• Other Opportunities…Real World

Agenda

• Discuss the importance of the organ donation referral process and

how it relates to the Electronic Medical Record (EMR)

• Explain how documented data within the EMR can be used to

consistently identify a specified population

• Identify clinical issues where use of innovative tools provide

quality outcomes and efficient shared clinical workflows to meet

the needs of several disciplines

Learning Objectives

What if?

• By United States Federal Law - OPOs are the only organizations

that can perform the recovery of organs from deceased donors

for transplantation

• OPO services include donor family support, clinical management

of organ donors, and professional and public education.

• All OPOs are regulated by multiple government agencies and

adhere to the highest medical and ethical standards.

• 58 OPOs in the United States

Organ Procurement Organizations (OPOs)

Association of Organ Procurement Organizations. (2018, October 31). About OPOs.

Retrieved from http://www.aopo.org/about-opos/

• Center for Medicare and Medicaid Services (CMS)

• Organ Procurement and Transplantation Network (OPTN)

• United Network for Organ Sharing (UNOS)

• Food and Drug Administration (FDA)

Regulating Bodies for OPOs in the United States

Association of Organ Procurement Organizations. (2018, October 31). About OPOs.

Retrieved from http://www.aopo.org/about-opos/

Centers for Medicare and Medicaid Services

Requirements

• Hospitals that receive reimbursement from Medicare and/or Medicaid

must notify their local organ procurement organization (OPO) of all

deaths and *imminent deaths in a **timely manner. (CMS §482.45(a)(1))

• Hospitals are required to maintain a patient hemodynamically until OPO

is able to evaluate the potential donor and the donation request can be

made to the family. (CMS §482.45(a)(5))

*Imminent death is defined as a mechanically ventilated patient with a devastating

neurological injury or insult and missing at least two brain stem reflexes or a

Glasgow Coma Scale of 5 or less.

**Timely is defined as within one hour.

Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-

content/uploads/2018/07/Donor-Resource-ManualV1.pdf

Centers for Medicare and Medicaid Services

Requirements

• The perception that a family's grief, race, ethnicity, religion or socioeconomic

background would prevent donation should never be used as a reason not to

approach a family about donation. (CMS §482.45(a)(3-4))

• It is [OPO] responsibility to determine medical suitability for donation and

must evaluate every patient who meets initial criteria for donation.(CMS

486.344(b)(4))

Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-

content/uploads/2018/07/Donor-Resource-ManualV1.pdf

Non-compliance and Low Referral Rate

Implications

• Reduced organ, tissue and eye availability for patients in need of transplants

• Hospitals can be fined for non-compliance.

• Reports of low referral rates can be reported to CMS and a CMS Survey may

be conducted

Every ten minutes, someone is added to the national transplant waiting

list.

On average, 20 people die each day while waiting for a transplant

People need a lifesaving organ transplant (total waiting list candidates)

Association of Organ Procurement Organizations. (2018, October 31). About OPOs. Retrieved from

http://www.aopo.org/about-opos/

Image Source –Noun Projet

Donor

Saves Up to 8 Lives

Enhances 50+ Lives

Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-

content/uploads/2018/07/Donor-Resource-ManualV1.pdf

• Low rate of family consent

• Family concerns about religious, cultural and social beliefs

• Family concerns about body integrity and exact time of death

• Family emotional vulnerability

• Education, income, sex, and age of family members

• Late or non referrals due to missed indicators or time to make calls

Barriers to Donation

Bocci, M., D'Alò, C., Barelli, R., Inguscio, S., Prestifilippo, A., Di Paolo, S., … Sandroni, C. (2016). Taking

Care of Relationships in the Intensive Care Unit: Positive Impact on Family Consent for Organ

Donation. Transplantation Proceedings, 48(10), 3245-3250. doi:10.1016/j.transproceed.2016.09.042

• Work collaboratively with the healthcare team

• Review entire ICU population for health system continuously

• Make referrals to OPO in a timely manner

• Provide education about donation and transplantation to patient

families and obtain Organ Donation Consent

• Develop appropriate communication plans

• Support families

• Help and maximize the gifts of donation and transplantation.

Role of Single Donor Coordinator

• Review 691 ICU population for health system continuously for referrals

• Call in all hospital deaths to OPO

• Coordinate with Medical Examiner’s Office – all approvals and sign off for release of

every patient that dies in the hospital – over 1600 in 2018

• Perform a in depth chart review for compliance with Ohio law for deaths reportable to

Medical Examiner and Adult Protectives Service concerns

• Bedside meetings with family before and after death

• Emotional support, hand holding, and active listening to families facing end of life for

a loved one

• Coordinate with family to help navigate end of life concerns such as funeral home,

belongings, and autopsy options after death

Role of Four Family Liaisons

• Act as a family resource for any issues family may have after patient dies

• Help family with autopsy information and retrieving records

• Family support and resources - provide a soft place to get things handled in place

after death

• Coordinate special needs religious or otherwise the family may request

• Help find resources for cremation if family has financial need

• Assistance with body donation support if family chose body donation

• Process all invalid advanced directives and communicate through mail with patients

to clarify and correct invalid advance directives for all regional hospitals

• Coordinate removal of abandoned bodies for regional and main hospitals

Role of Four Family Liaisons – Cont.

• Bedside nurse identifying patients on a ventilator, with a Glasgow Coma

Score (GCS) less than 5 or 2 missing brain stem functions, and a

qualifying neurological injury and making the referral call

• OPO contacted only after patient expired or been extubated, disqualifying

patients based on non-timely referrals

• Family Liaisons reviewing ICU patient charts for qualifying data manually

• Clinician referrals to Donor Coordinator or Family Liaisons in ICUs

• Constant chart review on patients in ICU settings

• OPO referrals made when patients identified with all three qualifiers for

referral were identified as being met through manual process or Brain

Death or Cardiac Death was reported.

• All documentation performed on paper and not stored in EMR

Previous Workflow for Referral Identification

So what’s the problem?!?!

Many

patients

Information

Overload

Limited time Frame

Miscommunication

and Missed

Communication

Inconsistent Workflows

Limited Staff

Missed Opportunities

• Surface discrete data consistently filed on each patient

• Use data in a filter to show only patients who are referral appropriate

– GCS coma score less than 5

– Patient on a ventilator

– Neurological diagnosis or qualifying other diagnosis such as cardiac

arrest in active problem list

Solution

• Close workflow loop and communicate referrals to all workflow users

• One report shows all information needed by OPO, referring user, eHospital

etc in one place rather than manual search in chart

• Call information documented in one location can be seen by all involved in

referral process and patient care

New look, one location - Custom patient list filters out

patients not appropriate, shows qualifying factors of on

Vent, GCS less than 5 or two missing brainstem functions

Fill out call information in one location

• Call column allows user to fill in information and all other users

can see when call made and who was spoken to

One Report Used for All

• No discrete documentation of time of death

• Inconsistent use of workflow

• No discrete documentation of brain stem function assessment

• Buy-in from Clinicians

• Closed loop with all those involved in patient care

• Correct identification of qualifying diagnosis

• Metrics

Problems Encountered

Measuring Success

Quotes from workflow users

• “The algorithm has made the progress of searching for patient's

appropriate to refer to Lifebanc much easier and continues to

improve we work to sharpen the mechanisms used in the

algorithm. Very pleased with the efforts to date and those

forthcoming.”

• “This new format is way easier to interface with. It keeps it simple,

and straight-forward.”

• “It is very helpful to be able to find the GCS without actually

opening the pt's chart. But with this tool, we can hover over a

column on EPIC patient list and GCS pops up. This allows me to

decide whether or not to open a patient's chart in certain cases.

For example, if a person codes overnight, the arrest may not show

up in the 'problem list', so the algorithm may not pick up the case.”

• Situational Awareness

• Gradual changes in vital signs

• Mobile Device integration and bidirectional workflows

• Prioritization of patient care

• Reduction of Infection

• Care Bundle tracking

Other Opportunities

Abby

Permission to share photographs obtained.

June 23, 1994 - April 25, 2018

Today, we share a common space and join in a common cause.

Through the caring touch of our hearts and hands, we join our efforts to

care for all donor patients and for all who benefit from the gift of life.

For all the children, grandchildren, friends, and family who are touched

by what we do here today, may we remember that fresh hope and

dreams began with the gift of one person.

May we take a moment now, in silence, to honor the lives of those who

gave a stranger life.

Moment of Honor

Lifebanc Moment of Honor, read in the Operating Room prior to organ retrieval.

Lifebanc Donor Resource Manual

http://www.lifebanc.org/wp-content/uploads/2018/07/Donor-

Resource-ManualV1.pdf

Association of Organ Procurement Organizations

http://www.aopo.org/find-your-opo/

International Society for Organ Donation and Procurement

https://www.tts.org/isodp/resources/organ-donation-societies

The Alliance Leadership in Organ Donation and Transplantation

Organ Donation Toolbox https://organdonationalliance.org/organ-

donation-toolbox/

Resources and Additional Info

Please remember to complete your online session evaluation.

Stefanie Shimko-Lin, RN – Clinical Analyst

Cleveland Clinic

shimkos@ccf.org

https://www.linkedin.com/in/stefanie-lin-rn-a2b80a81/

Christine V. Chambers, BS, MTS – Donor Coordinator

Cleveland Clinic

chambec1@ccf.org

https://www.linkedin.com/in/christine-chambers-monkowski-538382136/

Questions